Timing of renal-replacement therapy for AKI in the ICU


Background: Acute kidney injury (AKI) in the ICU is associated with high mortality. It is hypothesized that earlier initiation of RRT may benefit patients by controlling fluid overload and reducing metabolic stress caused by electrolyte and acid-base imbalances. However, prior studies have been conflicting, with the IDEAL-ICU study (2018) demonstrating no improvement in 90-day mortality with early RRT in septic shock.

Dr. Cheryl Lee, Division of Hospital Medicine, Northwestern University, Chicago

Dr. Cheryl Lee

Study design: Open-label randomized controlled trial.

Setting: 168 hospitals in 15 countries.

Synopsis: Of ICU patients with severe AKI, 3,019 were randomized to either early or standard initiation of RRT. Early RRT was defined as occurring within 12 hours of eligibility; in the standard-therapy group, RRT was delayed until specifically indicated or if there was no improvement after 72 hours. Those needing immediate renal replacement or deemed likely to recover without need for RRT were excluded in order to study only those in whom ideal timing of dialysis was uncertain. There was no difference in 90-day mortality between the groups (43.9% vs. 43.7%; P = .92). Early initiation did not improve length of ICU stay, ventilator-free days, days out of the hospital, or quality of life. The early-initiation patients experienced more adverse events related to RRT and were more likely to have continued dependence on RRT at 90 days (10.4% vs. 6.0% in standard initiation). Of note, approximately 40% of those randomized to standard initiation never required RRT.

Bottom line: This large, multicenter, well-conducted trial demonstrates no benefit for early initiation of RRT in critically ill patients.

Citation: STARRT-AKI investigators. Timing of initiation of renal-replacement therapy in acute kidney injury. N Engl J Med. 2020;383:240-51. doi: 10.1056/NEJMoa2000741.

Dr. Lee is a hospitalist at Northwestern Memorial Hospital and Lurie Children’s Hospital and assistant professor of medicine, Feinberg School of Medicine, all in Chicago.

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